Kindergarten Screen And Visit Form_0

Kindergarten Screening and Visit Please complete both pages, sign and return this form with your application no later than Tuesday, December 15, 2009. Child’s Name ______________________________________ Birthdate______________ Parent/Guardian Name(s)___________________________________________________

If you are applying to Katherine Delmar Burke School and/or The Hamlin School, applicants must complete both a kindergarten screening off site, and a kindergarten visit to each school they are applying. Please go to www.kdbs.org/screening/ after November 1st to schedule your child’s kindergarten screening. These one-on-one assessments will be administered by independent screeners at the Congregation Emanu-El of San Francisco (2 Lake Street) in January 2010. The screening times are: 9:00 a.m., 10:00 a.m. and11:00 a.m. If you are also applying to Marin Country Day School, Mount Tamalpais School and/or St. Mark’s School, you have the option of completing the kindergarten screening at one of these schools in lieu of screening at Congregation Emanu-El. Screening results, with your permission, will be shared with the schools you indicate on this form. In addition to the screenings, all applicants will visit each school to which they are applying. Please select the date and time you would like to schedule your child’s visit to Burke’s on the following page.

I. Kindergarten Screening Location: Please indicate below where your child will have her screening completed. Testing Site

Please check one

Congregation Emanu-El, San Francisco (for Burke’s and Hamlin) Marin Country Day School Mount Tamalpais School St. Mark's School

(CONTINUED)

II. Schools to Receive Screening Results: Your signature on this form indicates your permission to share the results of the screening with the schools named below. Schools

Please check all that apply

Katherine Delmar Burke School The Hamlin School Marin Country Day School Mount Tamalpais School St. Mark's School

III. Kindergarten Visit at Katherine Delmar Burke School Please rate in order of preference from 1st to 3rd the date and time you would like your child to visit Burke’s. We will contact you to confirm the visit date and time. Saturday 9:00 - 10:00 a.m.

Saturday 11:30 a.m -12:30 p.m.

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January 9

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January 9

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January 16

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January 16

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January 23

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January 23

Please list if your child has any food allergies: ___________________________________

____________________________ __________________________________ Parent/Guardian Signature Parent/Guardian Name (Please Print)

___________ Date